Formalin instillation for ischemic proctitis with unrelenting hemorrhage: report of a case.

A case report of an elderly male with multiple medical problems and hemorrhagic, ischemic proctitis is presented. The proctitis was refractory to all other medical options but responded to topical instillation of 4 percent formalin.

Perianal lymphoma in a heterosexual and nonimmunocompromised patient: report of a case and review of the literature.

PURPOSE: This study was conducted to report a rare case of anorectal pathology. METHODS: We report a case of perianal lymphoma in a nonimmunocompromised, heterosexual patient and review the literature. RESULTS: A 67-year-old white male was found to have an ulcerated posterior anal mass. Biopsy revealed large cell lymphoma, B cell type, immunoblastic. There was no disseminated disease. The patient denied any homosexual activity and was HIV negative. There was complete resolution with chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone), and he remained disease free for six years. CONCLUSIONS: Rare anorectal pathology may mimic common conditions. Biopsies should be taken to rule out malignancy.

Nitroglycerin ointment for anal fissures: effective treatment or just a headache?

PURPOSE: Topical nitrates have been shown to cause nitric oxide-mediated relaxation of the internal anal sphincter. Previous reports have suggested initial efficacy in the treatment of anal fissures. The aim of this study was to assess the longer-term usefulness of this treatment. METHODS: Thirty-three patients with an anal fissure were treated with topical 0.3% nitroglycerin ointment, applied to the anoderm three times per day and after bowel movements. Patients were followed up by office visits and telephone calls until symptoms were completely resolved or treatment was noted to be ineffective or intolerable. RESULTS: Thirty-three patients were treated, 16 with acute fissures, and 17 with chronic fissures. Nitroglycerin was effective in 9 of 16 acute fissures (56%), and 7 of 17 chronic fissures (41%). Even when effective, 75% of patients reported an adverse reaction. CONCLUSIONS: Topical nitroglycerin was only effective in approximately one-half of patients with an anal fissure. There was a very high incidence of adverse reactions. In our experience nitroglycerin more often causes a headache than treats the symptoms of anal fissure.

Treatment of proctalgia fugax with topical nitroglycerin: report of a case.

PURPOSE: We report a single case of proctalgia fugax that responded to 0.3 percent nitroglycerin ointment. METHODS: Case report. RESULTS: A single case of proctalgia fugax responded to topical application of 0.3 percent nitro glycerin ointment with no significant side effects. CONCLUSIONS: Nitroglycerin ointment is a newly described treatment for several painful anal conditions. We describe a single case of levator spasm or proctalgia fugax responding to topical application of nitroglycerin. This is only a single case report, and conclusive evidence awaits completion of a controlled clinical trial.

Colonoscopy without sedation.

PURPOSE AND METHODS: Two hundred fifty-eight consecutive nonsedated colonoscopies were prospectively evaluated over an 18-month period. The cecum was intubated in 250 cases (97 percent). Polypectomies or biopsies were performed in 77 cases (31 percent). Indications for colonoscopy included history of polyps (32 percent), hematochezia (28 percent), family history of colon cancer (16 percent), prior history of colon cancer (9 percent), change in bowel habits (12 percent), abnormal flexible sigmoidoscopy (6 percent), and inflammatory bowel disease (3 percent). RESULTS: Sedation was withheld for the following reasons: patient preference (57 percent), medical problems (2 percent), prior resection (16 percent), surgeon preference (6.5 percent), lack of intravenous access (3 percent), and age (1 percent). Three patients (1.5 percent) required sedation to complete the procedure. Procedure-related pain was based on a scale from zero to three. One hundred thirty-nine patients (61 percent) rated their pain as either zero (no pain) or one (mild pain), and 217 patients (8 percent) indicated that they would prefer their next colonoscopy to be performed without sedation. One hundred twelve patients had previously undergone sedated colonoscopy. Ninety-two (92 percent) preferred nonsedated to sedated procedures. Average procedure time was 13.7 (range, 0.5 to 85) minutes. CONCLUSIONS: Several series have studied nonsedated endoscopic upper and lower gastrointestinal evaluations. None, however, have evaluated patient comfort and satisfaction. In our prospective series of 258 consecutive nonsedated colonoscopies, we found the procedure to be safe, effective, and well accepted.

The influence of local tumor ulceration on the effectiveness of endocavitary radiation for patients with early rectal carcinoma.

BACKGROUND: Endocavitary radiation therapy is an alternative to surgical therapy for some early rectal carcinomas. Careful patient selection is necessary to ensure good results. The purpose of this study was to examine the authors' experience with endocavitary radiation at their institution from 1984 to 1991 to determine which factors were associated with treatment failure to provide for better future patient selection. METHODS: Thirty-two patients with carcinoma of the rectum, not apparently involving the muscle wall, underwent 75-120 Gy of endocavitary radiation as potentially curative therapy. Treatment was given as a series of 2-4 doses of 30 Gy at three weekly intervals. Twenty-two patients had polypoid tumors, 5 sessile, and 5 ulcerated. RESULTS: After a mean follow-up of 43 months (range, 6-103 months), 4 of 5 patients (80%) with ulcerated tumors developed local recurrences, compared with only 4 of 27 (15%) with sessile or polypoid lesions. Not only was the incidence of local recurrence greater for patients with ulcerated tumors (P = 0.009), but the time to recurrence was shorter also (P = 0.0001). Tumor size, anterior or posterior location, and dose of radiation received did not affect the rate of recurrence. CONCLUSIONS: These results indicate that superficial polypoid and sessile rectal tumors can be managed successfully with endocavitary radiation. Ulcerating tumors are likely to recur locally within a short time and therefore should be considered for surgical treatment initially.

Intrarectal ultrasound in the evaluation of perirectal abscesses.

Experience with intrarectal ultrasonography (IRUS) is limited for the evaluation of perianal sepsis. The purpose of this article is to report our experience with IRUS in evaluating 24 cases of suspected perianal abscess and fistula. IRUS was performed intraoperatively using a Brüel & Kjaer (Model #1846; Naerum, Denmark) endoanal ultrasound scanner with a 7-MHz transducer. After completion of the IRUS, careful anorectal examination and appropriate surgical therapy were performed. At surgery, 19/24 patients were found to have perirectal abscesses, with all 19 cases correctly identified preoperatively by IRUS. In 12 cases (63 percent), IRUS correctly defined the relationship between the abscesses and sphincters by Parks' classification. At surgery, internal openings of fistulous tracts were found in 14/19 cases, but IRUS identified only 4/14 (28 percent). In 6/24 cases, IRUS and clinical evaluation did not demonstrate a perirectal abscess. The role of IRUS in the evaluation of perirectal abscess is evolving. Certainly, uncomplicated abscesses can be managed without ultrasonography. However, IRUS can be an adjunct to careful evaluation of complex perianal suppurative disease.

Ketorolac and patient controlled analgesia in the treatment of postoperative pain.

Ketorolac tromethamine (Toradol [Syntex, Palo Alto]), a new commercially available nonsteroidal antiinflammatory drug (NSAID), has appropriate solubility and minimal tissue irritation, making it suitable for intramuscular injection. Previously, NSAID have only been available for oral use in the United States for the treatment of pain. Ketorolac, the most potent NSAID known, relieves pain through inhibition of arachidonic acid synthesis at the cyclooxygenase level and has no central opioid effects. The results of previous studies using parenteral ketorolac in combination with patient administered narcotics have shown a 40 percent reduction in narcotic requirements. However, ketorolac is presently only approved for intramuscular injection and oral use in the United States. In a prospective, randomized study, we compared intramuscular ketorolac in combination with patient controlled intravenous narcotic analgesia (morphine) (PCA-M) to PCA-M alone for the control of pain after extensive colonic resections. The combination of intramuscular ketorolac and PCA-M provided equal pain relief with no increased side effects when compared with narcotics alone. However, narcotic requirements of the patients were decreased by an average of 45 percent. Ketorolac and narcotics in combination provide effective postoperative pain relief and significantly decrease narcotic requirements. This combination may be particularly beneficial in the subpopulation of patients especially prone to narcotic related complications.

The necessity of routine pathologic evaluation of hemorrhoidectomy specimens.

Unsuspected carcinoma of the anus found on routine pathologic analysis of specimens taken at hemorrhoidectomy is a rare occurrence. Rates of 1 to 2 per cent are quoted, but without the support of objective data. During the past 20 years, 21,257 hemorrhoidectomies have been performed at Ferguson Hospital. During that time period, only one instance of unsuspected carcinoma of the anus was diagnosed solely by microscopic analysis of a specimen that was taken at hemorrhoidectomy. Based on this information, we recommend selective rather than routine pathologic evaluation of hemorrhoidectomy specimens. All patients should undergo careful anorectal examination prior to hemorrhoidectomy. Repeat examination should be performed with the patient under anesthesia and all excised tissue should be visually and manually inspected by the operating surgeon. Any suspicious areas as based on preoperative evaluation, examination under anesthesia or inspection of excised tissue should be sent for gross and microscopic evaluation.

Does alpha sympathetic blockade prevent urinary retention following anorectal surgery?

Urinary retention is the most common complication after anorectal surgery, with rates as high as 52 percent reported. With the trend toward early discharge, avoidance of this complication is particularly important. Perioperative fluid restriction and the use of short-acting anesthetics have been shown to be effective in decreasing postoperative urinary retention rates but are not applicable in all cases. Reflex sympathetic stimulation, possibly as a result of perianal pain, may lead to increased muscular tone of the internal sphincter at the bladder neck. This theory had led to the effective use of alpha-adrenergic blockade in the treatment of established cases of urinary retention after anorectal surgery, herniorrhaphy, and major pelvic surgery. However, the prophylactic role of alpha blockade after anorectal surgery has not been studied. In a double-blind, prospective, randomized study, 51 patients were treated with either prazosin and alpha-adrenergic blocker or placebo prior to and immediately after elective anorectal surgery. Urinary retention rates were similar in the two groups. At this time, prophylactic alpha-adrenergic blockade is not recommended for the prevention of urinary retention after anorectal surgery.

Use of frozen section analysis in the treatment of basal cell carcinoma.

Frozen section margin verification has been used in the treatment of basal cell carcinoma at our institution for the past 13 years. A review of the last 450 cases has shown frozen section to be most helpful in treating recurrent tumors where microscopic tumor foci extend beyond clinical margins in 45% of cases. Frozen section analysis may be of value in selected patients with primary tumors, but its routine use is not indicated for the majority of these lesions, since complete excision is possible without relying on frozen section in 90% of cases.